Steve Jobs: Computer Geniuses and Medical Mysticism, a Very Bad Combination

Brilliant computer innovators may not be so brilliant in all domains.

It is well known, and well documented for many decades, that pancreatic cancer is often extremely aggressive and detected relatively late due to lack of early symptoms.

Its detection should lead to aggressive treatment ASAP, such as radiation/chemotherapy or the Whipple procedure, if the person is to survive.

I consider this tragic:

Jobs Tried Exotic Treatments to Combat Cancer, Book Says
New York Times
Steve Lohr
Oct. 21, 2011

… His early decision to put off surgery and rely instead on fruit juices, acupuncture, herbal remedies and other treatments — some of which he found on the Internet — infuriated and distressed his family, friends and physicians, the book says. From the time of his first diagnosis in October 2003, until he received surgery in July 2004, he kept his condition largely private … Mr. Jobs put off surgery for nine months, a fact first reported in 2008 in Fortune magazine.

(Per Yahoo finance) … he also was influenced by a doctor who ran a clinic that advised juice fasts, bowel cleansings and other unproven approaches, the book says, before finally having surgery in July 2004.

I would replace the term “doctor” above with the onomatopoeia imitating the noise made by females of the species Anas platyrhynchos.

Medical mysticism and “alternative therapies” may have their place, especially in hypochondriacs and for relatively minor problems (in my view, via the placebo effect), but not in dire, well studied conditions such as cancer of the pancreas. A brilliant computer entrepreneur, one of the world’s best, may have been unnecessarily lost due to the seduction of medical mysticism.

In such diseases, sadly, an Apple a day does not keep the doctor – or the grim reaper – away.

— SS

10/22/11 Addendum:

This story has a personal angle of sorts to it. In the early 1970’s when I began my fascination with computers, I became friends with Hank, a brilliant computer programmer and fellow ham radio enthusiast, shown stting in this picture from the George Washington High School (Phila., PA) 1973 yearbook in front of our high school’s DEC PDP-8/S:

Me (standing, right), Eric Benshetler (standing, left), and Hank O’Neill (sitting), 1973.

Hank had a distrust of medicine. I last saw him when I was in Residency, when he visited my home to see my ham radio setup. He became a programmer working on military weapons systems, the B1B bomber I was told. I was told this, unfortunately, at his funeral just a few years ago. He’d developed a severe respiratory infection and tried to “tough it out.”

He died at home, apparently of pneumonia. A few dollars worth of antibiotics would probably have saved him. At the funeral, his friends told me he spoke occasionally of his former computer friend who’d gone into medicine. I was quite sad at his funeral. All he’d needed to have done would have been to call me. I’m sure I could have talked him into treatment.

— SS

Quis Custodiet Ipsos Custodes?

HAPPY TIMES AT NIMH

Two weeks ago I discussed a Commentary in JAMA by Dr. Thomas Insel, Director of the National Institute of Mental Health. Over on Danny Carlat’s blog, Dr. Insel took exception to my linking him with Charles Nemeroff, and appeared to be putting distance between himself and Dr. Nemeroff. So, I did some checking, and a correction to one of my statements is in order.

I had said, “ … that Insel appointed Nemeroff as an advisor soon after he (Insel) moved to NIMH.” That was my recollection. It turns out what I recalled was instead Insel showcasing Nemeroff in the NIMH Director’s 7th Annual Research Roundtable June 10, 2003, a few months after Insel moved from Emory University to NIMH. Let the record stand corrected.

At that gala meeting, held at the National Press Club in Washington, DC, Dr. Insel characterized Nemeroff as one of the “real stars of NIMH’s research community…” Nemeroff used the occasion to pimp GlaxoSmithKline’s drug paroxetine (Paxil), showing data on change in platelet stickiness after Paxil in patients with heart disease and depression. This highlighting of Paxil by Nemeroff focused on the surrogate outcome of platelet function, and contained no evidence that Paxil modified any important clinical endpoints. Nevertheless, Nemeroff speculated liberally about the place of antidepressant drugs in managing heart disease. This is the sort of stuff Insel described at the Roundtable as “ … an excellent sampling of the Institute’s exciting research endeavors.”

My general point two weeks ago was that Dr. Insel, the Director of an NIH Institute, downplayed the seriousness of the ethics issues surrounding the seven academic psychiatrists he mentioned in his Commentary in JAMA. Though he spoke in platitudes about the need for transparency, the spirit of transparency did not move him to disclose his own close ties with Dr. Nemeroff, who is one of the seven. Lest there be any remaining doubt about those ties, here is Dr. Nemeroff lauding Dr. Insel at the 201st meeting of the National Advisory Mental Health Council September 13, 2002 in the presence of the NIH Director, Elias Zerhouni, MD. From the Minutes: Dr. Charles Nemeroff, Reunette W. Harris Professor and Chair, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, commended Dr. Zerhouni’s selection of Dr. Insel as the next NIMH Director and added that Dr. Insel is the epitome of courage defined as grace under pressure. Dr. Nemeroff added that Dr. Insel will leave his current position as a most beloved professor, a respected scientist, and a great person.

In the comments on Danny Carlat’s blog I called Dr. Insel’s objections to my linking him with Nemeroff disingenuous. I still think that. Dr. Insel and Dr. Nemeroff are closer than Insel now seems comfortable acknowledging. Their record of talking up each other is hard to ignore. The irregularities identified by Senator Grassley involving Nemeroff’s reporting to NIH, his conflict of interest, and his conflict of commitment occurred on Insel’s watch. Considering the appearance of cronyism in their relationship, is it even possible for Dr. Insel to investigate Dr. Nemeroff’s performance in areas like the Emory-GlaxoSmithKline-NIMH Collaborative Mood Disorders Initiative?

Bernard Carroll

Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?


Now as to the “meta issues” that might be playing out, here and elsewhere:

I’ve recently read the following online somewhere regarding discussion of the media and its biases:

I learned a long time ago that when people or institutions begin to behave in a matter that seems to be entirely against their own interests, it’s because we don’t understand what their motives really are .


I have always assumed that, at least organizationally speaking, healthcare organizations
wanted their EHR projects to succeed. While I have encountered individuals who seemed to want specific projects to fail, usually due to territorial or other fairly obvious political issues, I always thought a reasonable assumption about HC organizations is that they want clinical IT projects to succeed.What if that is a false assumption?

What if there are a critical mass of people in many healthcare organizations who, while afraid to express it openly, are in opposition to the inconveniences, costs, political battles, loss of power, fear of loss of ability to conceal substandard performance (a fear both at the practitioner level and the management level), etc., such that on balance what the organizational motives “really are” are

to cause EHR to fail?

This could explain the prevalence of the “large scale problems” noted, and explain resistance regarding hiring of the most qualified in clinical IT (i.e., formally trained medical informatics experts), who might actually be correctly perceived as the best people to

make this technology work.

Finally, the national push to EHR that started a few years ago with ONC and the “2014 goal” should have had the effect of a large increase in the desirability of people with formal informatics training. However, if the assumption that organizations want EHR to succeed is not correct, then a federal mandate might only increase the resistance to the best talent in empowered operational roles, out of resentment towards the mandate at the very least.

So, my question is: do healthcare organizations really want clinical IT to succeed, and are many of the “problems” seen that are often identified as “sociotechnical complexities” in reality the outcome of simmering opposition to EHR’s and other clinical IT, and the often nasty issues they create for everyone in a healthcare organization?

I am myself skeptical about this possibility, but again, there are no paradoxes, only false assumptions.

If the assumption about organizations wanting clinical IT success is even in part false, then those pressuring the healthcare industry to computerize as a means to save costs and improve quality may be barking up the wrong tree.

— SS

Notes:

[1] Most hospitals don’t use latest ordering technology. Oregon Health & Science University, http://www.eurekalert.org/pub_releases/2003-11/ohs-mhd112403.php (accessed Oct. 25, 2008)

[2] Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203

[3] Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405.

[4] Medical Records Institute, as reported in Modern Healthcare, October 30, 2007. http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071030/FREE
/310300002/0/FRONTPAGE (accessed Oct. 25, 2008)

[5] Granger [UK] says he is ‘ashamed’ of some systems provided. E-Health Insider, 10 Jul 2007, http://www.e-health-insider.com/news/item.cfm?ID=2854 (accessed Oct. 25, 2008)

[6] Current Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (ONC), http://www.os.dhhs.gov/healthit/barrierAdpt.html (accessed Oct. 25, 2008).

[7] “Electronic Health Records in Ambulatory Care – A National Survey of Physicians”, NEJM 359:50-60

King/Drew Now King-Harbor, but Woes Continue

We had previously posted (here, here and here) about the ongoing troubles at the medical center formerly known as King/Drew and since renamed Martin Luther King Jr – Harbor Hospital in Los Angeles, after the county hospital went from being flagship hospital for the Charles R Drew University of Medicine and Science to a part of Harbor-UCLA Medical Center. Long viewed as a symbol of progress for poor and minority patients in the city, it had fallen on very hard times, attributed to bad management that for a long time hid behind the banner of the hospital’s reputation in the community.

The troubles continue. The hospital regained notoriety after a patient who was left to writhe in pain on the Emergency Department floor eventually died. As the Los Angeles Times recapped the story (re-ordered to make it chronological),

[Edith Isabel] Rodriguez a California native, was poor and uninsured. She reportedly had a history of narcotics use and lived with various relatives.

A security videotape showing the woman writhing for 45 minutes on the floor of the emergency room lobby….

[In response to] 911 calls from Rodriguez’s boyfriend and a female bystander. One dispatcher curtly told the bystander that the situation was not an emergency; the other said there was nothing she could do because Rodriguez was already in a hospital.

[A] video show[ed]… her extended time on the floor and a janitor cleaning around her.

She died of a perforated bowel, which probably developed in the last 24 hours of her life, according to a coroner’s report.

Meanwhile, the Times also reported that

In new signs of turmoil at Martin Luther King Jr.-Harbor Hospital, officials said Tuesday the chief medical officer had been replaced and more than 40% of licensed vocational nurses and nursing assistants recently failed initial skills tests.

The disclosures came as the Los Angeles County Board of Supervisors, grappling with federal findings that the hospital continues to endanger patients, bluntly discussed preparations for possible closure of the public facility.

The people more directly involved in the case of Ms Rodriguez were treated more leniently, also according to the Times,

Six staff members at Martin Luther King Jr.-Harbor Hospital — including a nurse and two nursing assistants — saw or walked past a dying woman writhing on the floor of the emergency room lobby last month but did not help her, according to a report made public Friday.

Their discipline: a letter outlining how they should behave in the future.

The six are in addition to two others whose roles have already been made public by The Times: a contract janitor who cleaned the floor around the woman as she vomited blood and a triage nurse who oversaw the whole episode and pointedly refused requests to intervene.

The janitor was counseled verbally; the triage nurse was placed on leave and later resigned, the report said.

What we said last year about what was then King-Drew still seems relevant. A few lessons from this sorry story: in health care, it is often the whole institution and its most vulnerable constituencies that suffer for the mistakes made by top managers; and that bad managers can hide for a long time behind institutions that enjoy a favorable reputation. And to make an addendum, although we have been writing a lot lately about the shenanigans of pharmaceutical management, mismanagement, conflicts of interest, and corruption seem to afflict the leadership of all kinds of health care organization.

ADDENDUM (21 June, 2007) – See this post on The Health Care blog on King-Harbor’s plight.

No Protection for Whistle-Blowers: The Blumsohn – Procter & Gamble – Sheffield University Case

The (UK) Guardian reported the latest developments in the case of Dr. Aubrey Blumsohn at Sheffield University. We had posted earlier (here and here) how Dr. Blumsohn had attempted, in vain, to get access to the data from a research project that he was ostensibly leading, and to control the writing of research abstracts that was done supposedly in his name. His attempts were opposed by Procter & Gamble, the company that made the drug he was studying, and paid for the research. Sheffield University failed to support his efforts, and after he talked to the media about his problems, suspended him
from his duties.
It turns out that Dr. Blumsohn “warned the Journal of Bone and Mineral Research more than a year ago that he had grave doubts about some of the research it had published in his name.” At that time, Blumsohn wrote, “I am the first author on both abstracts and have serious concerns about the analysis which has been presented in my name, as first author. Is there a mechanism for comment or dissociation?” At first, no investigation was done. Now, “the Journal has confirmed that it will hold an inquiry into Blumsohn’s concerns.”
The Guardian also reported, “Ghostwriting and a lack of data for independent researchers are just two issues that worry academics. For years, scientists have argued that Britain needs a statutory body to investigate such problems, as well as to detect the most serious cases of academic fraud. Professor Ian Kennedy, chairman of the Healthcare Commission, has said there must be proper protection for whistleblowers. He said they were often ignored, victimised, or labelled as pathological.”
This case, like those of Dr. David Kern and of Dr. Nancy Olivieri in the 1990’s, (described here) illustrates how academics may be “victimised,” to use Dr. Kennedy’s term, when they try to secure the integrity of research in ways that offend vested interests. This case also illustrates how academic institutions seem to be willing to cooperate in this victimization, even when such actions undermine their mission to provide for free enquiry and free expression. Finally, it illustrates that at present, in neither the UK, Canada, nor the US are there organized means or protection for such victimized academics. Up to now, no health board, accrediting agency, or physicians’ organization has gone to bat for them.
Maybe the unfortunate case of Dr. Blumsohn will finally spur physicians and researchers to unite to defend their own core values. Until we make it safe for researchers to produce data that displeases the powers that be, why should we trust what data the powers that be allow us to see?

OASIS C2 to go into effect Jan 1, 2017


Please recall that OASIS C2 will go into effect Jan 1, 2017. 

All Assessments with M0090 before or on Dec 31, 2016 will need to use the OASIS C1/ICD 10 Item Sets and Manual.

All Assessments with M0090 on or after Jan 1, 2017 will need to use the OASIS C2 Item Sets and Manual.

All references are Download links on the bottom of this page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

Please note that the OASIS C2 Item set includes entirely new items and revised numbers for some items that have been collected previously. Compare the two item sets carefully. A useful reference YouTube video is at: https://www.youtube.com/watch?v=h3TtnxyLGQ0

OASIS training classes for 2017 are listed at http://www.co.train.org in Denver and Pueblo.

For further questions, please contact betty.metz@state.co.us 

Health Care and Essential Oils

Complementary
alternative medicine has been offered by health care providers and holistic
practitioners as an answer to help resolve certain maladies that people want as
options to be treated versus traditional medicine. One of those methodologies
is the use of essential oils. Essential oils have been used for thousands of
years for their health, cosmetic, and emotionally uplifting properties.
Primarily extracted through careful steam distillation,
but also through cold pressing, the purest essential oils are far more powerful
and effective than dry herbs, delivering quick and effective results.

According
to www.YoungLiving.com, while some essential oils may uplift the spirits, others
may empower you to release negative thoughts and habits. Essential oils can be
your key to a more fulfilling and balanced emotional life.
Modern lifestyles don’t always create optimal conditions
for physical wellness. Poor diet, lack of exercise, and an overabundance of
environmental toxins can leave the body unbalanced and diminish energy levels.
From cleansing and weight management to supporting every system of the body,
essential oils and essential oil-infused supplements can provide the targeted
solutions you need to restore balance and feel your best.

Incense
and essential oils from plants have always played an important part in
religious and spiritual ceremonies, helping participants to transcend the
trivial and connect with something larger than themselves. Research shows that
the pure constituents in these oils stimulate olfactory receptors and activate
regions in the brain’s limbic system associated with memory, emotion, and state
of mind. For more detailed information on essential oils, visit this website: http://www.youngliving.com/en_US/discover/guide/about
.

Essential
oils are non water-based phytochemicals made up of volatile aromatic compounds.
Although they are fat soluble, they do not include fatty lipids or acids found
in vegetable and animal oils. Essential oils are very clean, almost crisp, to
the touch and are immediately absorbed by the skin. Pure, unadulterated
essential oils are translucent and range in color from crystal clear to deep
blue, according to this website: http://www.doterra.com/us/essentialDefinition.php
.

In
addition to their intrinsic benefits to plants and being beautifully fragrant
to people, essential oils have been used throughout history in many cultures
for their medicinal and therapeutic benefits. Modern scientific study and
trends toward more holistic approaches to wellness are driving a revival and
new discovery of essential oil health applications.

According
to www.DoTerra.com, topical application of essential oils can have immediate,
localized benefit to the target area. They have restorative and calming
properties and can be used effectively with massage and beauty therapy. They
are also natural disinfectants. The chemical structure of essential oils also
allows them to be absorbed into the bloodstream via the skin for internal
benefit throughout the body.

Essential
oils can also be used as dietary supplements supporting a variety of healthy
conditions. Some essential oils have powerful antioxidant properties while
others help support healthy inflammatory response in cells. Many essential oils
are generally regarded as being safe for dietary use, but some oils should not
be taken internally. Do not use any essential oil product internally that does
not have the appropriate dietary supplement facts on its label.

Using
essential oils can be both profoundly simple and life changing at the same
time. Working with someone who has used essential oils before will help
first-time users have a more beneficial and enjoyable experience. A large
amount of information is readily available for those desiring to increase their
knowledge of essential oil applications.

(Be sure
to use only 100 percent pure, therapeutic-grade essential oils and follow all
label warnings and instructions. Essential oils should not be used in the eyes,
inside the ear canal, or in open wounds. If redness or irritation occurs when
using essential oils topically, apply any vegetable oil, such as fractionated
coconut oil or olive oil, to the affected area. Consult your physician before
using essential oils if you are pregnant or under a doctor’s care.)

According
to www.CrunchyBetty.com, here are the top 7 essential oils to consider when you
want to start using them in your personal care products or homemade cleaning
supplies:

·        
Peppermint
(good for lip balms, oily/acneic skin, and cleaning products)

·        
Rosemary
(good for hair preparations, oily/acneic skin, and cleaning products)

·        
Sweet
orange (good for all skin types and very soothing in room sprays for children)

·        
Rose
geranium (good for all skin types, creating perfumes, and for use in homemade
moisturizers)

·        
Tea
tree (great for healing, getting rid of dandruff, oily/acneic skin, and
cleaning products)

·        
Lavender
(great for all skin types, for relaxation, hair preparations, and cleaning
products)

·        
Lemon
(great for lifting moods, cleaning preparations, and sparingly in toners and
products for oily skin)

All of
these essential oils also happen to be some of the least expensive and easiest
to find. Here are some references for learning more about how to safely and
effectively use essential oils in skincare, aromatherapy, and cleaning
products:

 

·        
Aromaweb.com is the best source for all things
aromatherapy on the internet

·        
Wavelengths Natural Health has an abundance of information on
essential oil profiles and aromatherapy

·        
All
of the essential oil profiles on Mountain
Rose Herbs.com
contain descriptions, usage, and precautions

·        
The
book Aromatherapy: Soothing Remedies to
Restore, Rejuvenate, and Heal
contains an incredible amount of level-headed
knowledge and recipes using essential oils

·        
The Essential Oils Book by Colleen K. Dodt is small, but
chock full of great info

·        
And
The Complete Book of Essential Oils and
Aromatherapy
is one last book to look for when learning more (and for more
great recipes)

Essential
oils have many affects on the human body, most of which are very therapeutic
when used in correct application. It also makes sense to talk with your family
physician about the use of essential oils, especially if you have certain
health or medical conditions that may be affected by their use. Most
individuals are not adversely affected, but it always makes sense to research
what is best for you.

Medical Economics: Highly experienced physicians lost to medicine over bad health IT

The title of the article is actually “Physicians leaving profession over EHRs“, but that title omits the real impact of the phenomenon: seasoned physicians, along with their medical expertise, judgment and experience, are lost to the pool of people entrusted to provide care thanks to poorly designed and badly implemented IT:


http://cci.drexel.edu/faculty/ssilverstein/cases/
Bad Health IT is IT that is ill-suited to
purpose, hard to use, unreliable, loses data or provides incorrect data, is
difficult and/or prohibitively expensive to customize to the needs of different
medical specialists and subspecialists, causes cognitive overload, slows rather
than facilitates users, lacks appropriate alerts, creates the need for
hypervigilance (i.e., towards avoiding IT-related mishaps) that increases
stress, is lacking in security, lacking in evidentiary soundness, compromises patient privacy or otherwise
demonstrates suboptimal design and/or implementation.

This is yet another article observing that the trajectory of health IT is not what the pioneers who taught me Medical Informatics intended:

Physicians leaving profession over EHRs
Medical Economics

January 24, 2018
http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-leaving-profession-over-ehrs

Until recently, most doctors created their own workflows
and utilized only the technology they were comfortable using. But with
the implementation of the Health Information Technology for Economic and
Clinical Health Act (HITECH Act) in 2009 to stimulate the adoption of electronic health records (EHR),
many physicians are finding things a bit too stressful.

In fact, a new
study in Mayo Clinic Proceedings showed that physicians who are
uncomfortable using EHRs are more likely to reduce hours or leave the profession.

I think it very fair to say that a majority of physicians are “uncomfortable” or at least “highly displeased” using today’s EHRs.  Evidence for this assertion includes, among others, the Jan. 2015 letter from approximately 40 medical societies including AMA, American College of Physicians, American College of Surgeons, and many sub-specialty societies expressing their displeasure directly to HHS. 

See my January 28, 2015 essay “Meaningful Use not so meaningful: Multiple medical specialty societies
now go on record about hazards of EHR misdirection, mismanagement and
sloppy hospital computing”
at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html, and the Medical Societies letter itself at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.

The research showed that while EHRs hold great promise
for enhancing coordination of care and improving quality of care, in its
current form and implementation, it has created a number of unintended
negative consequences including reducing efficiency, increasing clerical
burden and increasing the risk of burnout for physicians.

Typical of the anodyne stories in the media on bad health IT, the issue of causing increased risk and actual patient harm is omitted.

Tom Davis, MD, FAAFP, who practiced family medicine for almost 25 years
in the greater St. Louis area, says the primary reason he walked away
from a successful practice was the EHR, citing its use, the ethics and
the burden.

“I had 3,000 patients, many I’ve known for a quarter century, a few
hundred of which I delivered, all immensely valuable relationships
—and
all burned to the ground mostly because of the burdens of the HITECH
Act,” he says. “The demands of data entry, the use of that data to
direct care and my overall uncertainty about how medical data was used
in aggregate all helped poison the well from which my passion for
serving my patients was drawn.

In other words, his expertise, knowledge and experience, and valuable personal relationships (enhancing trust and the obtaining of the best medical histories) with his patients was sacrificed to, in essence, utopians’ notions of cybernetic medicine and the wants of the financialization-of-medicine sector.

He believes that the information collected through the EHR is being used
(at least in aggregate) for purposes other than the direct benefit of
the individual patient so it would be unethical for him to represent
otherwise to the patient. 

I had previously written on this site about the EHR companies trafficking in medical data, as in my October 7, 2009 essay “Health IT Vendors Trafficking in Patient Data?” at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.

In the research realm, formerly working with one of the key figures in the now-defunct Human Genome Diversity Project at Yale, I myself am personally aware of indigenous peoples refusing to take part in data collection by western scientists because they feared misuse of the data. 

I was right; the researcher proposed, and may have experimented with, using the genetic data to perfect a “forensic” identification capability essentially based on ethnic (“population”) origins. 

I wrote on these issues at my September 8, 2005 essay “Academic abuses in biomedicine vs. Indigenous Peoples: The Genographic Project” at http://hcrenewal.blogspot.com/2005/09/academic-abuses-in-biomedicine-vs.html and my July 26, 2007 essay “Informed consent, exploitation and ‘Developing a SNP panel for forensic identification of individuals’” at http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html.

I thus opine Dr. Davis’ concerns are quite legitimate.

As far as the burden, he notes he spent about
four minutes of keyboard time for every minute of face-to-face time with
a patient.

That is a huge waste of clinician time, with few proven benefits (at least outside the financial world) and known risk, e.g., ECRI Institute’s yearly “Top ten technology risks in healthcare” where health IT is usually highly ranking on that list, such as at my April 2014 essay at http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html.

Ramin Javahery, MD, chief of adult and pediatric neurosurgery at Long
Beach Memorial, Long Beach, California, says there are obvious financial
pressures that drive people out of private practice into a larger
corporate structure, but the changes in the workplace brought about by
EHRs are also driving older doctors to retire rather than deal with the
costs or increased work required.

“Younger physicians who are comfortable with typing, computers and the
truncated patient interactions generated by EHRs
do not resist its
presence,” he says. “Older physicians, however, are more likely to lack
those comforts. When faced with a less comfortable work environment,
they choose to retire, especially since many have saved enough to be
comfortable financially.”

Where do I even start?  Older doctors have a wealth of experience and hard-earned wisdom that is being sacrificed to the whims of those who think the medical robots of “Silent Running” are just on the horizon, it seems…

These robots could perform surgery.

Regarding younger (i.e., less experienced) physicians and the “truncated patient interactions generated by EHRs“, those are two deleterious results of the technology.  Less experience combined with less patient interaction, plus the distractions imposed by EHR-related clerical work, create increased risk of error and patient adverse consequences.   There is little to debate on that point.

Kevin Gebke, MD, a family and sports medicine practitioner at Indiana
University Health in Indianapolis, says the issue is not fear, rather
it’s a matter of dramatic workflow change.

“EHRs were not designed by practicing clinicians and are not intuitive
regarding the different processes that take place during a patient
encounter,” he says. “Physicians must often choose between communicating
with the patient and navigating within the records to enter or view
relevant data. That can fragment care
during a patient visit.”

His experience with EHRs is it has slowed down his workflow, causing a significant decrease in productivity.


The issue is certainly not “fear” or physicians being “Luddites”, as I’ve pointed out in my March 11, 2012 essay “Doctors and EHRs: Reframing the ‘Modernists v. Luddites’ Canard to The Accurate ‘Ardent Technophiles vs. Pragmatists’ Reality” at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html

The tension is not between doctors who “fear” technology or are Luddites, vs. the modernists.  Rather, the true tension is between clinician pragmatists and technology hyper-enthusiasts (“Ddulites”) who ignore technology’s clinical downsides.

“Spread this decreased capacity to see patients across the country and
we then have a magnified shortage of primary care providers,” Gebke
says.

That shortage is, in fact, at odds with national policy on re-populating the pool of generalists to reduce costs.

Because of this, he believes a way to keep physicians from leaving the
profession over EHR issues is to get them involved in design and
improvement processes.

EHR redesign can only accomplish so much.  I have reached the point where I believe the only solution to this seeming conundrum is to stop focusing on computers, and decouple physicians and nurses from cybernetic oppressionSee my August 9, 2016 essay “More on uncoupling clinicians from EHR clerical oppression” at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

I observed:

… In 2016, one of the largest complaints of hundreds of thousands of U.S.
physicians and nurses is that they spend more time interacting with the
computer than with patients
.  Patients complain they cannot get eye
contact from clinicians – who are tethered to a computer screen entering
data – during “live” encounters.

It is my belief there is no solution to this problem other than, where
appropriate and advantageous, decoupling clinicians from data input and
returning to paper for data entry, that is, specialized forms as in the
aforementioned post.
 Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

Finally, the predictable “things are getting better and utopia is just around the corner” ending to articles on the impact of bad health IT ends this Medical Economics article:
  

Things are improving

Munzoor Shaikh, director of West Monroe’s healthcare and life sciences
practice in Chicago, says that while some doctors are leaving medicine
due to technology learning curves, the industry is past the EHR
implementation phase and has entered an EHR optimization phase where the
user experience on the physician side should be improving.

“Those who have more patience than others have stuck around; hopefully
this optimization phase will save some more doctors from leaving,” he
says. “That said, there are some physicians who are fundamentally not
built for this tech-driven world
.”

The final line is nothing short of outrageous.

The truth is, there are all to many clinical information systems that are fundamentally not built for the good-practice-of-medicine-driven world.

— SS

Transformational and Disruptive Changes to Healthcare Delivery

More chronic illnesses, more old
age impairments, consumers demanding more quality and convenience, physicians
no longer in typical private practice, and high deductible health care polices
are each about to cause major changes in the practice of medicine and how it is
delivered to patients. 

 

Health care delivery will
change substantially in the coming years. This is not because of reform but
rather due to a set of drivers that are exerting a great push and pull to the delivery
system. Some of these changes will be quite transformational and some will be
very disruptive of the status quo. What are those drivers?

One of the most important is
that there will be many more individuals with chronic illness. The Milliken
Institute offered a white
paper
a few years ago on chronic illnesses and noted
that nearly one half of Americans had one or more
chronic illnesses, most of them preventable and 
which were costing the economy over $1 trillion per year and rapidly
rising. 

 

These are diseases like diabetes
with complications, heart failure, cancer, or chronic lung disease. What is
apparent is that they are mostly due to adverse lifestyles. Eating a non-nutritious
diet — and too much of it combined with a sedentary existence leads to
obesity. One third of Americans are overweight and another one third are
frankly obese. Add to this chronic stress and that 20% still smoke and there is
an effective recipe to produce chronic illnesses. Chronic illnesses will make
up a greater and greater proportion of all medical ailments as time goes on.
And of course they are more difficult to manage, generally last a lifetime and
are inherently expensive to treat (although there is much that can be done to
reduce the costs of care.)

 

A second driver of change is
the aging of the population. The American society is growing older and just
like a car:  “Old parts wear out.” Aging
brings on impaired vision, impaired hearing, impaired mobility, impaired bone
strength and impaired cognition among others – all as best we know today, not due
to adverse lifestyles but are tied into the aging process.

 

Consumerism is becoming –
finally – more and more of a driver of change. Patients are coming to expect to be treated like a valued
customer – “the patient is no longer willing to be patient any more.” What do
the patients want? They want service, good service. They are expecting high levels
of quality & safety. Most important of all is respect, respect for their
person, confidentiality, and the care quality. But also patients want convenience
& responsiveness. They want appointments in short order, no long times in
the “waiting room,” nor put on indefinite telephone hold. They want interaction
by email and other electronic methods.   And patients increasingly expect to have the
information gap closed– they expect the playing field between patient and
doctor to be much more level in the future.

 

Professional shortages are major
drivers of change in the delivery system. There have been shortages of nurse
and pharmacists noted for more than a decade. There is a growing shortage of primary
care physicians (PCPs) and also general surgeons. These shortages are more
acute in rural and urban poor areas.

 

Combined with shortages are
changes in professional aspirations and lifestyles. Today physicians want and
expect to have more time for family and recreation. And they no longer want to
run their own private practices. They prefer to be employed with little if any
administrative burdens. Indeed the number of PCPs in a typical private practice
arrangement has declined precipitously in recent years. 

 

These are but a few of the
drivers that will change the delivery of health care in dramatic ways in the
years ahead. I discuss them in much more detail in The Future of Health Care Delivery – Why It Must Change and How It Will
Affect You
with data obtained through over 150 in-depth interviews of
medical leaders from across the country.
Clearly physicians, patients, hospitals, insurers and employer/government
sponsors will be challenged to adapt.

 

 

Choosing a Good Physician

As a practicing family doctor, it’s easy for me to figure out how to choose a great doctor. Let me tell you the secrets in finding the best one for you and what I tell my family and friends.

Look for the following:

Board certification
Report card on quality
Licensing / public reporting

As a doctor, I know many doctors who have great bedside manner but aren’t particularly reliable in getting the right medical care you deserve and these traits separate the so-so doctors from the truly excellent ones.

If you’ve found one that meets all of the criteria and you know is in in your insurance plan, has convenient office hours and easy access, then I’ll give some tips on what to look for to determine if she has excellent bedside manner.

Importance of Board Certification
Your physician should be board certified in his field of expertise. Think of it as the difference between hiring a certified public accountant (CPA) and someone who just files taxes for you. While you might get the same result, if difficult issues come up, you may not get the best advice. Given how much we are all paying for medical care, why would you opt for someone who wasn’t board certified?

To carry this distinction, your doctor must have graduated from an accredited residency program as well as passed the passed the governing board’s certification exam. The examination may be a one-day or two-day written test. Depending on the medical specialty, test takers may also need to take an oral examination.

To maintain their board certification, physicians are required to devote a certain number of hours per year to additional medical education. Doctors often fulfill this requirement by attending conferences and seminars. In addition, doctors must re-certify with a repeat examination every few years to continue their status. Given all of these requirements, a board-certified doctor will often provide the most up-to-date medical care. Ensure that your doctor is board certified. As a recent article noted, doctors most likely to provide the wrong medical care for colon cancer screening were doctors who were NOT board certified.

Your physician may display his board certificate in the office. Some certificates may not have an expiration date because in the past, physicians only needed to take the exam once. It was good for life. This is no longer true. Current graduates can expect to retake the exam every seven to ten years.

Learn more and research your doctor at the American Board of Medical Specialties.

Report Card on Quality.
Find out if your doctor is practicing the latest most up to date medical care by checking out his report card on quality. Is he doing the right things to keep you healthy?

For example, unfortunately in the United States patients who have suffered a heart attack get drastically different care and many don’t get the life saving medication they need to prevent a future event. Less than 50 percent of heart attack patients in Mississippi receive this medication known as a beta blocker. Yet in Massachusetts, nearly every heart attack patient is taking it. This failure to prescribe the medication simply was whether the doctor consistently followed the guidelines established by the American Heart Association. It wasn’t whether the patient could afford the medication since all the patients received the same insurance, Medicare.

A review of 20,000 patients from 12 metropolitan areas showed that 24 percent of breast cancer patients, 27 percent of pre-natal patients, 31 percent of low back pain patients, 32 percent of coronary heart disease patients, and 35 percent of high blood pressure patients did NOT receive the recommended care developed by expert medical committees.

If your doctor isn’t doing the right things that experts recommend, then what else is he doing wrong?

See if your doctor has applied for the NCQA quality recognition designation in any of the following programs – Physician Practice Connections, Heart/Stroke, Diabetes, or Back Pain. This designation is like the Good Housekeeping Seal of Approval. To have this distinction, doctors must show the National Committee of Quality Assurance (NCQA) that they are doing the right things.

You can only use these aspect on primary care doctors (except for the physician practice connections which can be any doctor), like family doctors or internists, as other doctors don’t typically participate in these medical problems or illnesses.

Licensing / public reporting
Although your physician does not need to be board certified to practice medicine, he does need to be licensed. Find your own state medical board by going to the Federation of State Medical Boards or simply Google your state (like Connecticut) and medical board.

Each state provides different public information about its doctors. This typically includes the name of the physician, his license number, when the license was issued, and when it expires. Other states provide additional information like history of malpractice suits, felony convictions, or disciplinary action by the medical board. Some states split up the licensing and disciplinary functions into two different departments or websites. While at the state website, look for a link either for physician profile or credential search.

California State Medical Board
New York State Medical Board

The first three items, board-certification, report card on quality, and licensing / public reporting I know is unlikely things you would have come up with.

Bedside Manner
So now that you’ve found doctors that fulfill these basic requirements, what really is important for all of us is our doctors’ bedside manner. If you have friends who are medical assistants, nurses, or others in healthcare, ask for recommendations. Often they see us when we are the most stressed. If they like working with us, then it is likely that they will recommend us.

Not sure you got the best? Here is how you know.

Does she…
Sit down?
Listen?
Know your medical history?
Involve you in the decision making process or get your perspective?
Ask you – do you have any other questions?

Finally, most importantly, does she always wash her hands?

Follow this advice and feel extremely confident that you have a great doctor!